GC021 Upper Respiratory Tract Infections
Upper respiratory tract infections are acute infections affecting the nasal passages, pharynx, larynx, and sinuses, most commonly caused by viruses, presenting with symptoms such as nasal congestion, sore throat, cough, and malaise.
Upper Respiratory Tract Infections (URTIs)
This lecture (GC 021 / WCS 129) covers the single most common reason for medical consultation in primary care. The core message is deceptively simple but exam-critical: URTIs are overwhelmingly viral, self-limiting, and generally do not need antibiotics, investigations, or aggressive pharmacotherapy. The examiners test whether you can (1) define and classify URTIs, (2) distinguish them from serious mimics, (3) apply evidence-based (often non-) treatment, (4) use the Centor/McIsaac criteria correctly, (5) manage influenza including vaccination and antivirals, and (6) counsel on prevention.
Learning Objectives (directly from the lecture): [1]
- Define URTIs
- Be familiar with one of the commonest health problems
- Problem-solve common respiratory symptoms
- Diagnose URIs
- Evidence-based management of URTIs
This topic integrates with GC 106 (antibiotic stewardship), GC 052 (fever & purulent sputum — to differentiate LRTI), GC 215 (nasal conditions & NPC), GC 141 (cough in children), CFB WCS29 (ENT conditions including rhinosinusitis), and GC 101/105 (diagnosis of infections, medically important microbes).
"Self-limited irritation and swelling of the upper airways with associated cough and no signs of pneumonia, in a patient with no other condition that would account for their symptoms, or with no history of COPD, emphysema, or chronic bronchitis." [1]
"Involve the mucous membranes lining the upper respiratory tract from the nostrils and the mouth to the vocal cords in the larynx, also including the paranasal sinuses and the middle ear." [1]
Why this definition matters: The definition deliberately excludes lower respiratory signs (pneumonia, bronchospasm) and chronic airway disease. If a patient has signs of pneumonia (consolidation, crepitations, tachypnoea) or pre-existing COPD/emphysema, you cannot label it a simple URTI — this is a common exam trap.
Anatomical scope of the "upper respiratory tract":
- Nostrils → nasal cavity → paranasal sinuses
- Mouth → pharynx (naso-, oro-, hypo-)
- Larynx (down to the vocal cords)
- Middle ear (connected via Eustachian tube)
"> 90% viral; < 10% bacterial" [1]
This single fact drives virtually every management decision.
| Category | Organisms | Key Points |
|---|---|---|
| Viral ( > 90%) | Rhinovirus | Most common cause of common cold (30–50% of cases) |
| Adenovirus | Can also cause pharyngoconjunctival fever | |
| Influenza | Causes a distinct clinical syndrome (ILI) | |
| Parainfluenza | Major cause of croup in children | |
| RSV | Common in infants; leads to bronchiolitis | |
| Coronavirus | Includes seasonal strains and SARS-CoV-2 | |
| Bacterial ( < 10%) | Group A β-haemolytic Streptococcus (GAS) | Most important bacterial cause of pharyngitis |
| Haemophilus influenzae | Can cause sinusitis, otitis media, epiglottitis (type b) | |
| Streptococcus pneumoniae | Sinusitis, otitis media | |
| Branhamella (Moraxella) catarrhalis | Sinusitis, otitis media | |
| Staphylococcus aureus | Nasal vestibulitis, secondary infections |
Why > 90% viral matters clinically: Because antibiotics have zero efficacy against viruses. Prescribing antibiotics for viral URTI exposes patients to side effects and drives antimicrobial resistance — a key learning outcome of GC 106. [2]
"The most common infection in humans. Annual incidence: 2–3×/year (adults), up to 8×/year (children)." [1]
- Rarely lethal, often self-limiting, short in duration
- Despite this, creates a significant health and economic burden:
- ~900,000 annual attendances at public primary care clinics in HK [1]
- Manpower loss, school absenteeism
- Reason for consultation is usually symptom relief, not cure
"Common problems come first" — this is the family medicine principle. In the HK Primary Care Morbidity Survey 2007–08, URI was the #1 health problem at 26.4% of all consultations. [1]
| Rank | HK Survey 2007–08 (All PC) | Public GOPC |
|---|---|---|
| 1 | URI (26.4%) | Hypertension (25.7%) |
| 2 | Hypertension (10.0%) | URI (12.0%) |
| 3 | DM (4.0%) | DM (10.4%) |
| 7 | Acute bronchitis (2.4%) | — |
| 10 | Allergic rhinitis (1.3%) | — |
Why this matters for exams: Examiners love to test the "most common" — URI is the most common reason for primary care consultation in HK and globally. Note that respiratory conditions account for 36.2% of all primary care problems. [1]
4. Clinical Presentation
Symptoms usually begin 1–3 days after exposure and last 7–10 days, can persist up to 3 weeks. [1]
| Respiratory Symptoms | Systemic/Infection Symptoms |
|---|---|
| Cough / sputum | Chills |
| Runny nose / sneezing | General malaise |
| Nasal congestion | Fever (usually low-grade) |
| Sore throat | Loss of appetite |
| Hoarseness | Nausea / vomiting |
| Sneezing | Dyspepsia / abdominal pain |
Critical Exam Point
"Not all cough, runny nose & sore throat are URTIs." [1] — This statement appears prominently on the lecture slide. Examiners will present a patient with cough/sore throat and expect you to consider serious differentials before labelling it URTI.
4.2 Symptom Analysis — By Individual Symptom
"Not all cough & phlegm are due to URIs!" [1]
| Category | Conditions to Consider |
|---|---|
| Emergencies | Cyanosis, dyspnoea, drooling (think epiglottitis, foreign body) |
| Serious | Pneumonia, TB, cancer, CHF |
| Pitfalls | Allergic rhinitis, asthma, COPD, bronchiectasis, GERD, drug-induced (e.g. ACEI) |
Cough & phlegm in URTI specifically: [1]
- Acute irritating cough
- Scanty sputum, white/yellow
- Postnasal drip / sore throat
- Daytime & before or after sleeping
- General condition good, no SOB / chest signs
- Self-limiting, lasting 1–3 weeks
Symptom analysis framework — always assess:
- Nature: Dry vs. productive; sputum colour (white/yellow does NOT automatically = bacterial)
- Course: Acute ( < 3 weeks) / subacute (3–8 weeks) / chronic ( > 8 weeks) / recurrent
"Yellow nasal discharge may, but does not necessarily, equal bacterial infection." [1]
This is a classic misconception that examiners love to exploit. The colour of nasal discharge reflects the stage of inflammation and neutrophil activity, not necessarily bacterial involvement.
Differentials for runny nose (not all are common cold): [1]
| Category | Consider |
|---|---|
| Serious | NPC (nasopharyngeal carcinoma) — always consider in southern Chinese with unilateral bloody nasal discharge, serous otitis media, cranial nerve palsies |
| Pitfalls | Allergy, nasal polyps, foreign body (esp. in children — unilateral foul discharge), sinusitis |
| Complications | Otitis media, sinusitis |
Nasal symptoms in URTI specifically: [1]
- Acute onset
- Copious clear watery discharge
- Sneezing ++, relatively little itchiness (cf. allergic rhinitis where itchiness is prominent)
- Little diurnal variation (cf. allergic rhinitis which is often worse in the morning)
- Self-limiting, lasting 3–5 days
"> 90% acute sore throat due to viral URIs" [1]
| Category | Consider |
|---|---|
| Emergency | Acute epiglottitis (drooling of saliva, toxic appearance, "hot potato" voice, stridor) |
| Serious | Bacterial tonsillitis, peritonsillar abscess (quinsy), TB, lymphoma |
| Pitfalls | Postnasal drip, irritation, foreign body, infectious mononucleosis (EBV — think of this in young adults with prolonged sore throat, fatigue, lymphadenopathy, hepatosplenomegaly) |
Key clinical pearls: [1]
- Enlarged tonsils are normal in children — do not over-interpret tonsillar size alone
- Exudates can mean viral OR bacterial — exudate alone does NOT confirm bacterial aetiology (another common exam trap)
"Indicates pathology in the larynx. Most likely viral URI if acute." [1]
| DDx | Features |
|---|---|
| Vocal cord polyps/nodules | Chronic, associated with voice overuse |
| Acute epiglottitis | Emergency — drooling, stridor, toxic child sitting forward |
| Croup | Barking "seal" cough, inspiratory stridor, typically 6 months–3 years |
| Carcinoma of larynx | Chronic progressive hoarseness in smoker |
| Pitfalls | Sputum retention, laryngeal injury/compression, post-intubation trauma |
5. Centor / Modified McIsaac Criteria for Sore Throat
HIGH YIELD — Frequently Examined
The Centor criteria estimate the probability that pharyngitis is streptococcal and guide management decisions. [1] This is one of the most commonly tested clinical decision tools in URTI.
- History of fever (or temperature ≥ 38°C)
- Tonsillar exudates
- Tender anterior cervical lymphadenopathy
- Absence of cough
Why "absence of cough"? — Cough is a hallmark of viral URTI. Its absence raises the probability of a non-viral (bacterial, i.e. GAS) aetiology. This is a discriminator the examiners love.
- Age 3–14: Add 1 point (GAS pharyngitis is most common in school-age children)
- Age 15–44: Add 0 points
- Age ≥ 45: Subtract 1 point (GAS pharyngitis is uncommon in older adults)
- Score range: −1 to 5
| Score | Action |
|---|---|
| −1, 0, or 1 | No antibiotic or throat culture necessary |
| 2 or 3 | Consider rapid strep testing and/or culture; treat with antibiotic if positive |
| 4 or 5 | Consider rapid strep testing and/or culture; treat if positive |
The 2012 IDSA guidelines no longer recommend empiric treatment for strep based on symptomatology alone; they recommend testing patients at higher risk and not giving antibiotics until a rapid test or culture is positive. The overall aim is to avoid inappropriate use of antibiotics. [1]
Why this matters: Previously (McIsaac 1998), a score of 4–5 could warrant empiric antibiotics. The updated approach emphasises test-then-treat, which aligns with GC 106 (antibiotic stewardship). [2]
Exam Trap
A common trap is presenting a patient with a high Centor score and asking whether you should give empiric antibiotics. The current best answer is: test first (rapid antigen detection test or throat culture), then treat only if positive. Do not prescribe antibiotics based on clinical score alone.
If GAS pharyngitis is confirmed, why treat with antibiotics at all?
- Prevent suppurative complications (peritonsillar abscess, retropharyngeal abscess)
- Prevent acute rheumatic fever (ARF) — still relevant in developing countries
- Reduce symptom duration by ~1 day
- Reduce transmission
- First-line: Penicillin V (oral) or Amoxicillin for 10 days; if penicillin-allergic: macrolide (azithromycin)
6. Transmission & Prevention
"Transmission by contacts & droplets. Maximum viral shedding on D2 & D3. Virus found in 40% hand samples. Natural infectivity rate 38–88%. Median incubation 3 days (range 1–10). 70–90% infected are symptomatic. Diagnosis is clinical; viral culture possible; serology useless." [1]
Key points:
- Hand contact is the most important transmission route — hence hand hygiene is the single most effective preventive measure
- Droplet transmission also occurs (coughing, sneezing)
- Serology is useless because there are > 200 viral subtypes causing the common cold; by the time titres rise, the illness is over
- Personal hygiene: Hand washing, wearing masks
- Sleep: Participants with < 7 hours of sleep were 2.94× more likely to develop a cold; those with < 92% sleep efficiency were 5.50× more likely [1]
- Sleep quality and quantity are independent predictors, even after controlling for antibody titres, demographics, BMI, psychological variables, etc.
- Influenza vaccination (see Section 8)
Exam Factoid — Sleep vs Vitamin C
Daily Vitamin C has NOT been proven to prevent the common cold. Adequate sleep (≥ 8 hours) IS proven to reduce susceptibility. [1] This was a specific interactive question in the lecture.
7. Natural Course & Investigation
Mean resolution 2–3 days, 75th percentile resolution 7 days (cough up to 10 days). [1]
| Symptom | Duration Range |
|---|---|
| Cough | 2–20 days |
| Headache | 1–14 days |
| Hoarseness | 2.5–20 days |
| Muscle ache | 2–14 days |
| Runny nose | 2–14 days |
| Sore throat | 2–14.3 days |
Why knowing natural history matters: Patients (and some clinicians) become anxious when cough persists beyond a few days. Knowing that cough can last up to 3 weeks in a simple URTI prevents unnecessary antibiotics, investigations, and referrals.
"Any investigation needed?" [1] — The lecture poses this as a rhetorical question to emphasise that most simple URTIs need no investigations.
| Scenario | Investigation Indicated? |
|---|---|
| Simple common cold | No — clinical diagnosis |
| Influenza | Consider rapid antigen test / PCR (NPA/NPS), but "rapid test not more accurate than clinical diagnosis" [1] |
| Pharyngitis | Rapid strep test / throat culture if Centor ≥ 2 |
| Suspected pneumonia | CXR, sputum culture, blood tests |
| Prolonged or atypical course | Guided by clinical suspicion (CXR, CBC, CRP, etc.) |
8. Management
"Body's immune system is most effective. Curative treatment is usually not needed. Symptomatic treatment — not a pill for every illness/symptom — evidence-based — benefit vs. harm." [1]
"Antibiotics and steroids are not doing any good for viral URTI. Side effects of drugs. Antibiotic resistance." [1]
| Treatment | Evidence | Notes |
|---|---|---|
| Paracetamol | Proven effective & safe | First-line for fever and sore throat pain |
| NSAID (ibuprofen) | More effective than paracetamol but more side effects | GI irritation, renal effects; useful for severe sore throat |
| Aspirin | Contraindicated in children with influenza | Risk of Reye's Syndrome (acute hepatic encephalopathy) |
| Lozenges | No large-scale quality trials | May provide local comfort |
| Steroids | Do more harm than good | No role in simple URTI |
HIGH YIELD
"NO good evidence for the effectiveness of over-the-counter cough medicines." [1] — This is a key slide message. Reassurance about the natural course of cough (can persist up to 3 weeks) is more important than prescribing cough medicines.
| Drug Class | Examples | Evidence | Concerns |
|---|---|---|---|
| Opioid antitussives | Codeine, pholcodine, dextromethorphan | Uncertain effectiveness for URTIs; NOT recommended in children | Sedation, GI disturbances, abuse potential |
| Non-opioid antitussives (sedating antihistamines) | Diphenhydramine, dexbrompheniramine | Inconsistent RCT results | Blurred vision, dry mouth, urinary retention |
| Expectorants | Ammonium chloride (MES), ipecacuanha, guaifenesin (Robitussin), squill | Effectiveness not proven by RCT (some evidence for guaifenesin) | High dose → nausea & vomiting |
| Mucolytics | Bromhexine | Loosens bronchial secretions | Dizziness, headache, GI disturbance |
| Beta-agonists (inhaled/oral) | Salbutamol | May be effective for prolonged cough, especially with bronchial hypersensitivity | Palpitations, tremor; seldom necessary |
Safety warnings for children: [1]
- FDA: No cough and cold product with decongestant or antihistamine for kids < 2 years — "serious and possibly life-threatening side effects could occur"
- Health Canada/NHS: No OTC cough and cold medicine for kids < 6 years
| Treatment | Evidence | Notes |
|---|---|---|
| Non-selective antihistamines (e.g. chlorpheniramine) | May reduce sneezing & rhinorrhoea | Sedating; some benefit in URTI |
| Non-sedating selective antihistamines | Much less effective for URTI nasal symptoms | Better for allergic rhinitis |
| Nasal decongestants (pseudoephedrine, PPA) | May provide transient relief of nasal obstruction | Side effects common and can be serious; caution in hypertensive patients |
| Topical ipratropium (Atrovent) | Treatment option for nasal congestion in children > 6 and adults | Expensive |
| Heated humidified air | Conflicting results | Benign and possibly beneficial |
"NO proven efficacy of antihistamines or decongestants in children and adults for URI." [1]
"FDA warning: Avoid decongestants in children < 2 years." [1]
"Shotgun therapy increases side effects." [1]
- Combination cough & cold products contain mixtures of antitussives, antihistamines, expectorants, decongestants
- Risk of overdosing in children; associated with sudden infant deaths [1]
- Beware of:
- Aspirin (salicylate) in children → Reye's syndrome
- Phenylpropanolamine (PPA) → risk of haemorrhagic stroke (withdrawn in many countries)
- Antihistamine overdose when cold medicine + cough mixture prescribed together
- Hand washing — most effective single measure
- Wearing masks — reduces droplet spread
- Rest and stress reduction [1]
9. Influenza — A Distinct Entity Within URTIs
"Three types of influenza viruses affecting humans: A, B, and C." [1]
"Criteria of ILI (Influenza-Like Illness): fever ≥ 38°C + cough and/or sore throat." [1]
| Feature | Influenza | Common Cold |
|---|---|---|
| Onset | Abrupt | Gradual |
| Fever | High (≥ 38°C), prominent | Low-grade or absent |
| Systemic symptoms | Severe systemic upset, generalised myalgia | Mild malaise |
| Nasal symptoms | Mild | Prominent |
| Cough | Dry, can be prominent | Irritating, scanty sputum |
| Self-limiting? | Most cases; complications (mostly pneumonia) in 5–20% | Almost always |
| Diagnosis | Clinical; rapid test not more accurate than clinical Dx | Clinical |
"Effective in preventing illness, complications, hospitalization and death." [1]
Types of influenza vaccines available in HK: [1]
| Type | Route | Population |
|---|---|---|
| Inactivated influenza vaccine | IM (most) | ≥ 6 months old |
| Live attenuated influenza vaccine | Intranasal | Non-pregnant, non-immunocompromised, age 2–49; caution: children < 5 with recurrent wheezing/asthma may have ↑ risk of wheezing |
| Recombinant influenza vaccine | IM | ≥ 18 years; produced without eggs or live virus; may be more effective in older adults |
Timing and efficacy: [1]
- Efficacy: reduces risk of influenza by 40–60% when circulating viruses closely match vaccine strains
- Should be given annually at the beginning of peak season (Oct–Nov) in HK
- Effective 2 weeks post-vaccination
Priority groups for influenza vaccination: [1]
| Group | Why |
|---|---|
| Healthcare workers | Prevent nosocomial transmission |
| Institutionalised persons | High-risk setting |
| Age ≥ 50 years | Higher complication risk |
| Chronic medical conditions | Chronic lung/cardiovascular/renal/metabolic disease, obesity (BMI ≥ 30), immunocompromised, chronic neurological conditions |
| Children & adolescents (6 months–18 years) | Higher attack rate, school transmission |
| Pregnant women | Risk to mother and fetus |
| Poultry workers / pig farmers | Zoonotic transmission risk |
| Children/adolescents on long-term aspirin | Risk of Reye's syndrome with influenza |
| Drug | Route | Key Side Effect |
|---|---|---|
| Oseltamivir (Tamiflu®) | Oral | Nausea and vomiting |
| Zanamivir (Relenza®) | Inhaled | Bronchospasm |
| Peramivir (Rapivab®) | IV | Diarrhoea |
| Baloxavir marboxil (Xofluza®) | Oral | Well-tolerated; single-dose convenience |
Key points: [1]
- Shorten illness by about 1 day if given within 48 hours of symptom onset
- Reduce complications (especially secondary bacterial pneumonia)
- Not routinely needed for all influenza; reserved for severe cases, high-risk patients, or hospitalised patients
From Maksim's notes / GC 106 context: [3][2]
- Oseltamivir and zanamivir are neuraminidase inhibitors
- Baloxavir is a cap-dependent endonuclease inhibitor (novel mechanism)
- Infection control: Droplet precautions for seasonal influenza; airborne precautions for novel influenza strains
From the lecture and supporting ENT material:
| Complication | Mechanism |
|---|---|
| Acute otitis media | Eustachian tube dysfunction → middle ear effusion → secondary bacterial infection [1][5] |
| Acute rhinosinusitis | Mucosal oedema obstructs sinus ostia → trapped secretions → bacterial superinfection [6] |
| Lower respiratory spread | Viral descent → acute bronchitis, bronchiolitis (in infants with RSV), pneumonia |
| Asthma exacerbation | Viral-induced airway hyperreactivity |
| Peritonsillar abscess (quinsy) | Untreated or severe bacterial tonsillitis → abscess formation |
From the past paper (2020 MCQ Q52): A patient with 4 months of yellowish nasal discharge post-URTI + bilateral nasal obstruction + mucopus from middle meatus → this is chronic rhinosinusitis. The first-line treatment is intranasal steroid spray (Answer B). [7]
From the past paper (2023 MCQ Q65): A child with otalgia, hearing loss, fever, erythematous TM post-URTI → acute otitis media (Answer C). [8]
| Condition | Key Distinguishing Features |
|---|---|
| Common cold (URTI) | Nasal symptoms predominate, cough, hoarseness, self-limiting 7–10 days |
| Influenza | Abrupt onset, high fever, severe myalgia, systemic upset > nasal symptoms |
| GAS pharyngitis | Centor ≥ 3, sudden sore throat, NO cough, exudates + tender anterior cervical LN |
| Allergic rhinitis | Itchiness prominent, watery rhinorrhoea, sneezing, diurnal variation, atopic history |
| Acute rhinosinusitis | URTI symptoms > 10–14 days + facial/sinus pain, purulent discharge, fever [4] |
| Pneumonia | Fever, productive cough, tachypnoea, crepitations, consolidation signs |
| Acute epiglottitis | Drooling, toxic, dysphagia, muffled voice, stridor — medical emergency |
| Croup | Barking cough, inspiratory stridor, age 6 months–3 years |
| NPC | Unilateral blood-stained nasal discharge, serous otitis media, cranial nerve palsies in southern Chinese |
| Pertussis | Paroxysmal cough with "whoop," post-tussive vomiting, no fever in paroxysmal phase |
| Infectious mononucleosis (EBV) | Prolonged sore throat, fatigue, generalised lymphadenopathy, hepatosplenomegaly, atypical lymphocytes |
From the lecture slides showing ENT examination images: [1]
Throat examination:
- Observe pharyngeal erythema, tonsillar enlargement, exudates, membrane formation
- Palpate anterior cervical lymph nodes
- Note: Exudates can be viral (EBV, adenovirus) or bacterial — do NOT assume bacterial
Ear examination (otoscopy): [1]
- Normal TM landmarks: cone of light, handle of malleus, umbo, lateral process, pars tensa
- Red, bulging TM → acute otitis media (common complication of URTI, especially in children)
- Dull TM with effusion → otitis media with effusion (OME)
Nasal examination:
- Anterior rhinoscopy / nasal endoscopy
- Look for polyps, foreign body, mucopus from middle meatus (sinusitis), deviated septum
"Antibiotics and Steroids are not doing any good for viral URTI." [1]
"Describe strategies to reduce unnecessary antibiotic treatment for acute upper respiratory tract infections" — this is a specific learning outcome of GC 106. [2]
Strategies to reduce unnecessary antibiotic prescribing in URTI:
- Educate patients on the viral aetiology and self-limiting nature
- Use clinical scoring (Centor/McIsaac) to identify who truly needs testing/treatment
- Test-then-treat — do not give empiric antibiotics for sore throat; wait for rapid strep or culture result
- Delayed prescribing — give a prescription with instructions to fill it only if symptoms worsen after 3–5 days (reduces antibiotic use without increasing complications)
- Set realistic expectations — cough can last up to 3 weeks; runny nose 3–5 days; reassurance is therapeutic
- Avoid combination cold preparations — "shotgun therapy" increases side effects without proven benefit
"URIs are common and highly infectious. Not all URT symptoms are caused by infection. Different URIs have different pathogenesis & natural courses. Curative treatments are limited and usually unnecessary. Benefit of symptomatic treatments needs to be balanced against harm. Personal hygiene and influenza vaccine are very important in prevention. Flu anti-viral drugs may be considered in patients with influenza depending on circumstances." [1]
Past-Paper Style MCQ/SAQ/Minicase Stems:
-
A 30-year-old woman presents with 3 days of sore throat, fever, and tonsillar exudates. She has no cough. Anterior cervical nodes are tender. What is her Centor score and what is the next step?
- Score = 4 (fever + exudates + tender anterior cervical LN + absence of cough). Next step: Rapid strep test/throat culture → antibiotics only if positive. Do NOT give empiric antibiotics.
-
A mother brings her 18-month-old child with cough and runny nose for 2 days. She requests cough medicine. What do you advise?
- OTC cough and cold medicines are NOT recommended for children < 2 years (FDA) or < 6 years (Health Canada/NHS). Reassure that cough is self-limiting. Hand hygiene. Rest.
-
A 60-year-old man with hypertension has a common cold. Which nasal decongestant consideration is important?
- Pseudoephedrine/PPA can elevate blood pressure — use with caution or avoid in hypertensive patients.
-
A 45-year-old man has had yellowish nasal discharge and bilateral nasal obstruction for 4 months post-URTI. Nasal endoscopy shows mucopus from both middle meati. What is the first-line treatment?
- Intranasal steroid spray (chronic rhinosinusitis). [7]
-
Which of the following is proven more effective in preventing the common cold: daily Vitamin C or daily ≥ 8 hours of sleep?
- Sleep. Vitamin C at onset of illness has no benefit. [1]
-
A child with influenza is given aspirin. What complication are you most worried about?
- Reye's syndrome (acute hepatic encephalopathy + fatty liver degeneration).
-
Name 4 anti-influenza drugs, their routes, and one side effect each.
- See Section 9.3 table above.
-
Explain why antibiotics should not be prescribed for a typical viral URTI.
-
90% viral → no benefit from antibiotics; risk of adverse drug reactions; drives antimicrobial resistance; adds unnecessary cost.
-
High Yield Summary
- URTIs are > 90% viral, self-limiting (7–10 days), and the most common reason for primary care consultation (~26% of all PC visits in HK).
- Diagnosis is clinical. Investigations are rarely needed for simple URTI.
- Not all cough, sore throat, and runny nose = URTI. Always exclude emergencies (epiglottitis, foreign body), serious conditions (pneumonia, TB, NPC, cancer), and pitfalls (asthma, COPD, allergic rhinitis, GERD, drugs).
- Centor/McIsaac criteria guide sore throat management: test-then-treat (no empiric antibiotics based on score alone per 2012 IDSA).
- Symptomatic treatment: Paracetamol is first-line. OTC cough medicines have NO good evidence. Avoid cough/cold medicines in children < 2 (FDA) or < 6 (Health Canada/NHS). Aspirin is contraindicated in children with influenza (Reye's syndrome).
- Yellow nasal discharge ≠ bacterial infection.
- Exudates on tonsils can be viral or bacterial.
- Antibiotics and steroids have no role in viral URTI.
- Prevention: Hand washing > sleep ≥ 8 hours > influenza vaccination. Vitamin C at illness onset has no benefit. Zinc > 75 mg/day within 24 hours may shorten illness by 1–3 days.
- Influenza: ILI = fever ≥ 38°C + cough/sore throat. Antivirals (oseltamivir etc.) shorten illness by ~1 day if started within 48 hours. Vaccination is effective (40–60%) and should be annual.
Active Recall - Upper Respiratory Tract Infections
[1] Lecture slides: GC 021. Upper respiratory tract infections.pdf (all pages) [2] Lecture slides: GC 106. Practical issues in antibiotic use.pdf (p2, p37); GC 106. Practical issues in antibotic use [Notes].pdf (p1) [3] Senior notes: Maksim Medicine Notes.pdf (p189 — Influenza section) [4] Senior notes: Ryan Ho Respiratory.pdf (p48 — URTI section) [5] Senior notes: Adrian Lui Pediatrics Notes.pdf (p154–156 — URTI and acute coryza) [6] Lecture slides: CFB WCS29_Common ENT conditions 2023.pdf (p15 — Rhinosinusitis) [7] Past papers: 2020 Fourth Summative Assessment MCQ paper.pdf (Q52) [8] Past papers: 2023 Fourth Summative MCQ.pdf (Q65)
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